hospital_name,last_updated_on,version,location_name,hospital_address,license_number|MA,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name
McLean Hospital,2026-03-27,3.0.0,McLean Hospital,115 Mill St Belmont MA 02478-1064,2920,1538185475,true,Daniel Morash
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","code|4","code|4|type","modifiers","setting","drug_unit_of_measurement","drug_type_of_measurement","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|min","standard_charge|max","standard_charge|methodology","additional_generic_notes"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","19478.00","14608.50","AETNA [1001]","HB MCL MEDICARE","1184.00","","Case rate ($1,184.00) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","222.13","100.00","35554.28","1 through 10","1184","1184","other","Inpatient Psych"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","19478.00","14608.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","1184.00","","Case rate ($1,184.00) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","382.50","82.14","18392.64","1 through 10","1184","1184","other","Inpatient Psych"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","19478.00","14608.50","MEDICARE [2001]","HB MCL MEDICARE","1184.00","","Case rate ($1,184.00) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","2524.00","2524.00","2524.00","1 through 10","1184","1184","other","Inpatient Psych"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","19478.00","14608.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1184.00","","Case rate ($1,184.00) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","179.23","84.24","1185.15","1 through 10","1184","1184","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18292.00","13719.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","1041.48","","Case rate ($1,041.48) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","246.14","82.14","6256.08","31","1041.48","1041.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18292.00","13719.00","MEDICARE [2001]","HB MCL MEDICARE","1041.48","","Case rate ($1,041.48) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7298.75","6591.46","10375.55","1 through 10","1041.48","1041.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18292.00","13719.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1041.48","","Case rate ($1,041.48) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","170.00","50.73","351.46","26","1041.48","1041.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18292.00","13719.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICARE","1041.48","","Case rate ($1,041.48) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","179.23","50.73","1704.27","11","1041.48","1041.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","9767.00","7325.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","942.82","","Case rate ($942.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","284.69","246.42","6199.47","1 through 10","942.82","942.82","other","Inpatient Psych"
"Anesthesia, Elctroshock / Ect","PX-37000032","CDM","00104","CPT","0370","RC","","","","outpatient","","","216.00","162.00","AETNA [1001]","HB MCL AETNA","119.45","55.3","","122.69","122.69","122.69","103","108","164.16","percent of total billed charges",""
"Anesthesia, Elctroshock / Ect","PX-37000032","CDM","00104","CPT","0370","RC","","","","outpatient","","","216.00","162.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","129.60","60","","216.00","216.00","216.00","14","108","164.16","percent of total billed charges",""
"Anesthesia, Elctroshock / Ect","PX-37000032","CDM","00104","CPT","0370","RC","","","","outpatient","","","216.00","162.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","116.01","53.71","","115.34","115.34","115.34","81","108","164.16","percent of total billed charges",""
"Anesthesia, Elctroshock / Ect","PX-37000032","CDM","00104","CPT","0370","RC","","","","outpatient","","","216.00","162.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","139.97","64.8","","216.00","216.00","216.00","38","108","164.16","percent of total billed charges",""
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","43565.00","32673.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1216.89","","Case rate ($1,216.89) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","537.87","180.12","2731.54","1 through 10","1216.89","1216.89","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","24734.00","18550.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","1162.08","","Case rate ($1,162.08) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","3553.44","3553.44","3553.44","1 through 10","1162.08","1162.08","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","24734.00","18550.50","MEDICARE [2001]","HB MCL MEDICARE","1162.08","","Case rate ($1,162.08) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","6783.25","6783.25","6783.25","1 through 10","1162.08","1162.08","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","24734.00","18550.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1162.08","","Case rate ($1,162.08) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","152.90","105.54","1431.52","1 through 10","1162.08","1162.08","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","24734.00","18550.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICARE","1162.08","","Case rate ($1,162.08) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","542.63","542.63","6681.92","1 through 10","1162.08","1162.08","other","Inpatient Psych"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","","","","inpatient","","","26505.00","19878.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1282.67","","Case rate ($1,282.67) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","587.13","587.13","587.13","1 through 10","1282.67","1282.67","other","Inpatient Psych"
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","105.00","78.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","68.04","64.8","","65.18","65.18","65.18","1 through 10","13.54","79.8","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","580.00","435.00","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","369.77","417.6","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","580.00","435.00","MGB HEALTH PLAN [150001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.81","362.81","1 through 10","369.77","417.6","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","500.00","375.00","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","1 through 10","360","369.77","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","155.00","116.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","69.41","69.41","1 through 10","70.53","111.6","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","155.00","116.25","MEDICARE [2001]","HB MCL MEDICARE","70.53","","APC Price ($70.53). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","70.54","141.08","1 through 10","70.53","111.6","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB MCL CIGNA","77.50","50","","56.00","56.00","56.00","1 through 10","70.53","117.8","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","155.00","116.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","100.44","64.8","","25.19","25.19","25.19","1 through 10","70.53","117.8","percent of total billed charges",""
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","852.00","639.00","AETNA [1001]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","601.95","164.64","649.20","154","601","1196","other","OPPS APC"
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","852.00","639.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","573.28","89.74","620.04","208","601","1196","other","OPPS APC"
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","852.00","639.00","MEDICARE [2001]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","1349","601","1196","other","OPPS APC"
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","852.00","639.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.33","107.29","107.33","946","601","1196","other","OPPS APC"
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","outpatient","","","852.00","639.00","AETNA [1001]","HB MCL AETNA","471.16","55.3","","282.53","282.53","282.53","103","457.61","3652.92","percent of total billed charges",""
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","outpatient","","","852.00","639.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","457.61","53.71","","620.04","620.04","620.04","83","457.61","3652.92","percent of total billed charges",""
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","outpatient","","","852.00","639.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","630.06","","APC Price ($630.06).","401.36","105.14","617.52","203","457.61","3652.92","other","OPPS APC"
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","both","","","172.00","129.00","AETNA [1001]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","601.95","164.64","649.20","154","123.84","630.06","other","OPPS APC"
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","both","","","172.00","129.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","573.28","89.74","620.04","208","123.84","630.06","other","OPPS APC"
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","both","","","172.00","129.00","MEDICARE [2001]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","1349","123.84","630.06","other","OPPS APC"
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","both","","","172.00","129.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","630.06","","APC Price ($630.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.33","107.29","107.33","946","123.84","630.06","other","OPPS APC"
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","outpatient","","","172.00","129.00","AETNA [1001]","HB MCL AETNA","95.12","55.3","","282.53","282.53","282.53","103","92.38","3652.92","percent of total billed charges",""
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","outpatient","","","172.00","129.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","92.38","53.71","","620.04","620.04","620.04","83","92.38","3652.92","percent of total billed charges",""
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","outpatient","","","172.00","129.00","MASSHEALTH ALTERNATE [3003]","HB MCL MEDICAID","111.46","64.8","","694.05","694.05","694.05","78","92.38","3652.92","percent of total billed charges",""
"Electroconvulsive Therapy","PX-98301335","CDM","90870","CPT","0961","RC","","","","outpatient","","","172.00","129.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","630.06","","APC Price ($630.06).","401.36","105.14","617.52","203","92.38","3652.92","other","OPPS APC"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","both","","","448.00","336.00","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","500.05","128.38","500.05","1 through 10","322.56","322.56","other","OPPS APC"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","both","","","448.00","336.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.22","80.06","477.22","1 through 10","322.56","322.56","other","OPPS APC"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","both","","","448.00","336.00","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.03","81.03","81.03","1 through 10","322.56","322.56","other","OPPS APC"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","both","","","448.00","336.00","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","409.89","485.18","37","322.56","322.56","other","OPPS APC"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","both","","","448.00","336.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.39","81.36","84.03","17","322.56","322.56","other","OPPS APC"
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","outpatient","","","448.00","336.00","AETNA [1001]","HB MCL AETNA","247.74","55.3","","355.50","299.61","355.50","1 through 10","240.62","344","percent of total billed charges",""
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","outpatient","","","448.00","336.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","268.80","60","","266.60","266.60","590.00","18","240.62","344","percent of total billed charges",""
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","outpatient","","","448.00","336.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","240.62","53.71","","233.36","233.36","254.16","1 through 10","240.62","344","percent of total billed charges",""
"Exam Neurobehavrl by Psych per Hr","PX-90000039","CDM","96116","CPT","0918","RC","","","","outpatient","","","448.00","336.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","252.09","82.95","348.62","11","240.62","344","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","94.18","94.18","197.14","13","107.28","107.28","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","149.00","111.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","476.06","187.57","476.06","96","107.28","107.28","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","149.00","111.75","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.55","55.55","55.55","14","107.28","107.28","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","149.00","111.75","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","190.81","1229.67","397","107.28","107.28","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","149.00","111.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","72.78","71.99","72.78","179","107.28","107.28","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","outpatient","","","149.00","111.75","AETNA [1001]","HB MCL AETNA","82.40","55.3","","213.57","213.57","213.57","15","80.03","344","percent of total billed charges",""
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","outpatient","","","149.00","111.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","80.03","53.71","","554.85","103.07","554.85","1 through 10","80.03","344","percent of total billed charges",""
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","outpatient","","","149.00","111.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","71.33","71.29","72.75","23","80.03","344","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","223.00","167.25","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.14","125.35","501.29","65","160.56","160.56","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","223.00","167.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","70.87","187.76","129","160.56","160.56","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","223.00","167.25","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.46","73.46","82.25","32","160.56","160.56","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","223.00","167.25","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","254.39","94.11","254.39","1 through 10","160.56","160.56","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","223.00","167.25","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","572.43","567","160.56","160.56","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","223.00","167.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","96.03","72.02","96.07","371","160.56","160.56","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","223.00","167.25","AETNA [1001]","HB MCL AETNA","123.32","55.3","","323.76","323.76","323.76","330","119.77","344","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","223.00","167.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","119.77","53.71","","187.76","187.76","593.83","18","119.77","344","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","223.00","167.25","MASSHEALTH [3001]","HB MCL MEDICAID","144.50","64.8","","369.36","369.36","369.36","1 through 10","119.77","344","percent of total billed charges",""
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","outpatient","","","223.00","167.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","71.44","27.84","96.03","40","119.77","344","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","337.00","252.75","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","188.27","422.57","1 through 10","242.64","242.64","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","337.00","252.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.32","104.86","314.57","105","242.64","242.64","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","337.00","252.75","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","121.79","121.79","121.79","1 through 10","242.64","242.64","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","337.00","252.75","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","139.25","139.25","139.25","1 through 10","242.64","242.64","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","337.00","252.75","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","485.18","271","242.64","242.64","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","337.00","252.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","142.09","106.61","142.15","197","242.64","242.64","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","337.00","252.75","AETNA [1001]","HB MCL AETNA","186.36","55.3","","442.47","442.47","442.47","165","181","466.76","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","337.00","252.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","181.00","53.71","","653.11","653.11","653.11","13","181","466.76","percent of total billed charges",""
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","outpatient","","","337.00","252.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","104.99","27.84","142.09","86","181","466.76","other","OPPS APC"
"HC Psych W/Patient W/E&M Srvcs 30 Min","PX-90000051","CDM","90833","CPT","0914","RC","","","","outpatient","","","126.00","94.50","AETNA [1001]","HB MCL AETNA","69.68","55.3","","190.84","190.84","190.84","28","67.67","344","percent of total billed charges",""
"HC Psych W/Patient W/E&M Srvcs 30 Min","PX-90000051","CDM","90833","CPT","0914","RC","","","","outpatient","","","126.00","94.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","67.67","53.71","","179.42","179.42","179.42","62","67.67","344","percent of total billed charges",""
"HC Psych W/Patient W/E&M Srvcs 45 Min","PX-90000053","CDM","90836","CPT","0914","RC","","","","outpatient","","","207.00","155.25","AETNA [1001]","HB MCL AETNA","114.47","55.3","","268.10","199.94","323.76","12","111.18","344","percent of total billed charges",""
"HC Psych W/Patient W/E&M Srvcs 45 Min","PX-90000053","CDM","90836","CPT","0914","RC","","","","outpatient","","","207.00","155.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","111.18","53.71","","252.05","252.05","252.05","29","111.18","344","percent of total billed charges",""
"HC Psych W/Patient W/E&M Srvcs 60 Min","PX-90000055","CDM","90838","CPT","0914","RC","","","","outpatient","","","332.00","249.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","178.32","53.71","","363.66","363.66","363.66","1 through 10","178.32","358.06","percent of total billed charges",""
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","237.00","177.75","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","94.18","94.18","197.14","13","170.64","170.64","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","237.00","177.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","476.06","187.57","476.06","96","170.64","170.64","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","237.00","177.75","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.55","55.55","55.55","14","170.64","170.64","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","237.00","177.75","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","190.81","1229.67","397","170.64","170.64","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","237.00","177.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","72.78","71.99","72.78","179","170.64","170.64","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","outpatient","","","237.00","177.75","AETNA [1001]","HB MCL AETNA","131.06","55.3","","213.57","213.57","213.57","15","104.36","344","percent of total billed charges",""
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","outpatient","","","237.00","177.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","127.29","53.71","","554.85","103.07","554.85","1 through 10","104.36","344","percent of total billed charges",""
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","outpatient","","","237.00","177.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","71.33","71.29","72.75","23","104.36","344","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","361.00","270.75","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.14","125.35","501.29","65","259.92","259.92","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","361.00","270.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","70.87","187.76","129","259.92","259.92","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","361.00","270.75","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.46","73.46","82.25","32","259.92","259.92","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","361.00","270.75","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","254.39","94.11","254.39","1 through 10","259.92","259.92","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","361.00","270.75","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","572.43","567","259.92","259.92","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","361.00","270.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","96.03","72.02","96.07","371","259.92","259.92","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","361.00","270.75","AETNA [1001]","HB MCL AETNA","199.63","55.3","","323.76","323.76","323.76","330","186.2","344","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","361.00","270.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","193.89","53.71","","187.76","187.76","593.83","18","186.2","344","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","361.00","270.75","MASSHEALTH [3001]","HB MCL MEDICAID","233.93","64.8","","369.36","369.36","369.36","1 through 10","186.2","344","percent of total billed charges",""
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","outpatient","","","361.00","270.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","71.44","27.84","96.03","40","186.2","344","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","461.00","345.75","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","188.27","422.57","1 through 10","331.92","331.92","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","461.00","345.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.32","104.86","314.57","105","331.92","331.92","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","461.00","345.75","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","121.79","121.79","121.79","1 through 10","331.92","331.92","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","461.00","345.75","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","139.25","139.25","139.25","1 through 10","331.92","331.92","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","461.00","345.75","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","485.18","271","331.92","331.92","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","461.00","345.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","142.09","106.61","142.15","197","331.92","331.92","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","461.00","345.75","AETNA [1001]","HB MCL AETNA","254.93","55.3","","442.47","442.47","442.47","165","247.6","466.76","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","461.00","345.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","247.60","53.71","","653.11","653.11","653.11","13","247.6","466.76","percent of total billed charges",""
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","outpatient","","","461.00","345.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","104.99","27.84","142.09","86","247.6","466.76","other","OPPS APC"
"Hcpr Psych W/Patient W/E&M Srvcs 30 Min","PX-96100031","CDM","90833","CPT","0961","RC","","","","outpatient","","","218.00","163.50","AETNA [1001]","HB MCL AETNA","120.55","55.3","","190.84","190.84","190.84","28","117.09","344","percent of total billed charges",""
"Hcpr Psych W/Patient W/E&M Srvcs 30 Min","PX-96100031","CDM","90833","CPT","0961","RC","","","","outpatient","","","218.00","163.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","117.09","53.71","","179.42","179.42","179.42","62","117.09","344","percent of total billed charges",""
"Hcpr Psych W/Patient W/E&M Srvcs 45 Min","PX-96100033","CDM","90836","CPT","0961","RC","","","","outpatient","","","277.00","207.75","AETNA [1001]","HB MCL AETNA","153.18","55.3","","268.10","199.94","323.76","12","148.78","344","percent of total billed charges",""
"Hcpr Psych W/Patient W/E&M Srvcs 45 Min","PX-96100033","CDM","90836","CPT","0961","RC","","","","outpatient","","","277.00","207.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","148.78","53.71","","252.05","252.05","252.05","29","148.78","344","percent of total billed charges",""
"Hcpr Psych W/Patient W/E&M Srvcs 60 Min","PX-96100035","CDM","90838","CPT","0961","RC","","","","outpatient","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","196.58","53.71","","363.66","363.66","363.66","1 through 10","196.58","358.06","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","75.00","56.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","48.60","64.8","","73.12","73.12","73.12","1 through 10","9.71","57","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","800.00","600.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","246.21","246.21","26","250.18","576","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","800.00","600.00","MEDICARE [2001]","HB MCL MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1033.93","250.21","1300.42","55","250.18","576","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","800.00","600.00","AETNA [1001]","HB MCL AETNA","442.40","55.3","","454.40","454.40","454.40","1 through 10","250.18","608","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","800.00","600.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","429.68","53.71","","246.21","246.21","465.28","1 through 10","250.18","608","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","800.00","600.00","CIGNA [1006]","HB MCL CIGNA","400.00","50","","400.00","400.00","400.00","1 through 10","250.18","608","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","800.00","600.00","PHCS MULTIPLAN [1022]","HB MCL CLARITEV (PRIMARY PPO)","608.00","76","","454.40","454.40","454.40","1 through 10","250.18","608","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","800.00","600.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","250.18","","APC Price ($250.18).","257.10","257.10","257.10","1 through 10","250.18","608","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0900","RC","","","","outpatient","","","800.00","600.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","480.00","60","","200.61","200.61","209.48","418","480","480","percent of total billed charges",""
"MRI Brain","PX-98301597","CDM","70551","CPT","0983","RC","","","","both","","","376.00","282.00","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","39","270.72","287.03","other","OPPS APC"
"MRI Brain","PX-98301597","CDM","70551","CPT","0983","RC","","","","both","","","376.00","282.00","MGB HEALTH PLAN [150001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.09","262.09","262.09","1 through 10","270.72","287.03","other","OPPS APC"
"MRI Brain","PX-98301597","CDM","70551","CPT","0983","RC","","","","both","","","376.00","282.00","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","628.77","628.77","628.77","1 through 10","270.72","287.03","other","OPPS APC"
"MRI Brain","PX-98301597","CDM","70551","CPT","0983","RC","","","","outpatient","","","376.00","282.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","201.95","53.71","","282.47","282.47","282.47","1 through 10","188","829","percent of total billed charges",""
"MRI Brain","PX-98301597","CDM","70551","CPT","0983","RC","","","","outpatient","","","376.00","282.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","291.16","287.06","291.16","1 through 10","188","829","other","OPPS APC"
"MRI Brain","PX-98301597","CDM","70551","CPT","0983","RC","","","","outpatient","","","376.00","282.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","243.65","64.8","","411.27","411.27","411.27","1 through 10","188","829","percent of total billed charges",""
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","both","","","578.00","433.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","415.63","415.63","1 through 10","416.16","424.07","other","OPPS APC"
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","both","","","578.00","433.50","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","1015.16","39","416.16","424.07","other","OPPS APC"
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","both","","","578.00","433.50","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.87","419.87","419.87","1 through 10","416.16","424.07","other","OPPS APC"
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","outpatient","","","578.00","433.50","FALLON HEALTH [1008]","HB MCL MEDICAID","374.54","64.8","","1697.00","1697.00","1697.00","1 through 10","289","1200.44","percent of total billed charges",""
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","outpatient","","","578.00","433.50","MASSHEALTH [3001]","HB MCL MEDICAID","374.54","64.8","","2026.00","2026.00","2026.00","1 through 10","289","1200.44","percent of total billed charges",""
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","outpatient","","","578.00","433.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","458.44","458.44","458.44","1 through 10","289","1200.44","other","OPPS APC"
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","outpatient","","","578.00","433.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","374.54","64.8","","819.12","819.12","819.12","1 through 10","289","1200.44","percent of total billed charges",""
"MRI Brain Combo","PX-98301599","CDM","70553","CPT","0983","RC","","","","outpatient","","","578.00","433.50","WELLSENSE [1003]","HB MCL MEDICAID","374.54","64.8","","458.09","458.09","458.09","1 through 10","289","1200.44","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5654.00","4240.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","415.63","415.63","1 through 10","424.07","4070.88","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5654.00","4240.50","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","1015.16","39","424.07","4070.88","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5654.00","4240.50","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.87","419.87","419.87","1 through 10","424.07","4070.88","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5654.00","4240.50","FALLON HEALTH [1008]","HB MCL MEDICAID","3663.79","64.8","","1697.00","1697.00","1697.00","1 through 10","424.07","4297.04","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5654.00","4240.50","MASSHEALTH [3001]","HB MCL MEDICAID","3663.79","64.8","","2026.00","2026.00","2026.00","1 through 10","424.07","4297.04","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5654.00","4240.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","458.44","458.44","458.44","1 through 10","424.07","4297.04","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5654.00","4240.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","3663.79","64.8","","819.12","819.12","819.12","1 through 10","424.07","4297.04","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5654.00","4240.50","WELLSENSE [1003]","HB MCL MEDICAID","3663.79","64.8","","458.09","458.09","458.09","1 through 10","424.07","4297.04","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4352.00","3264.00","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","39","287.03","3133.44","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4352.00","3264.00","MGB HEALTH PLAN [150001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.09","262.09","262.09","1 through 10","287.03","3133.44","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4352.00","3264.00","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","628.77","628.77","628.77","1 through 10","287.03","3133.44","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4352.00","3264.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","2337.46","53.71","","282.47","282.47","282.47","1 through 10","277.27","3307.52","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4352.00","3264.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","291.16","287.06","291.16","1 through 10","277.27","3307.52","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4352.00","3264.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","2820.10","64.8","","411.27","411.27","411.27","1 through 10","277.27","3307.52","percent of total billed charges",""
"MRI Brain W/O Cont|REDUCED SERVICES","PX-61000016","CDM","70551","CPT","0611","RC","","","52","both","","","4352.00","3264.00","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","133.72","133.72","133.72","1 through 10","287.03","287.03","other","OPPS APC"
"MRI Brain|REDUCED SERVICES","PX-98301597","CDM","70551","CPT","0983","RC","","","52","both","","","376.00","282.00","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","133.72","133.72","133.72","1 through 10","287.03","287.03","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5623.00","4217.25","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","419.73","1015.16","1 through 10","424.07","4048.56","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5623.00","4217.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","1015.16","1015.16","1015.16","1 through 10","424.07","4273.48","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3849.00","2886.75","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","22","287.03","2771.28","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3849.00","2886.75","MGB HEALTH PLAN [150001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.50","265.29","554.50","1 through 10","287.03","2771.28","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3849.00","2886.75","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.19","264.24","284.19","1 through 10","287.03","2771.28","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3849.00","2886.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","291.16","287.06","291.16","1 through 10","275.04","2925.24","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5558.00","4168.50","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","848.22","419.73","1863.38","1 through 10","424.07","4001.76","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3825.00","2868.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","287.03","2754","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3825.00","2868.75","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","45","287.03","2754","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3825.00","2868.75","MGB HEALTH PLAN [150001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","853.56","853.56","853.56","1 through 10","287.03","2754","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3825.00","2868.75","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","286.32","262.30","633.77","1 through 10","287.03","2754","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3825.00","2868.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","2054.41","53.71","","282.47","282.47","282.47","1 through 10","275.29","2907","percent of total billed charges",""
"MRI L-Spine W/O Cont|REDUCED SERVICES","PX-61000028","CDM","72148","CPT","0612","RC","","","52","both","","","3825.00","2868.75","MEDICARE [2001]","HB MCL MEDICARE","307.41","","APC Price ($307.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","307.41","307.41","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5718.00","4288.50","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","424.07","4116.96","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","5718.00","4288.50","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.87","419.87","419.87","1 through 10","424.07","4116.96","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5796.00","4347.00","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","424.11","1 through 10","424.07","4173.12","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5796.00","4347.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","3113.03","53.71","","424.11","424.11","424.11","1 through 10","424.07","4404.96","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4319.00","3239.25","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","641.60","1 through 10","287.03","3109.68","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4319.00","3239.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","284.12","203.70","284.12","1 through 10","287.03","3282.44","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","5187.00","3890.25","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","424.11","1015.16","1 through 10","424.07","3734.64","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3860.00","2895.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","287.03","2779.2","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3860.00","2895.00","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","1 through 10","287.03","2779.2","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3860.00","2895.00","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","286.32","286.32","286.32","1 through 10","287.03","2779.2","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3754.00","2815.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","291.16","291.16","291.16","1 through 10","287.03","2853.04","other","OPPS APC"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","4076.00","3057.00","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","281.82","287.06","1 through 10","287.03","2934.72","other","OPPS APC"
"MRI, Cerv Spine","PX-98301608","CDM","72141","CPT","0983","RC","","","","both","","","377.00","282.75","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","22","271.44","287.03","other","OPPS APC"
"MRI, Cerv Spine","PX-98301608","CDM","72141","CPT","0983","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.50","265.29","554.50","1 through 10","271.44","287.03","other","OPPS APC"
"MRI, Cerv Spine","PX-98301608","CDM","72141","CPT","0983","RC","","","","both","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.19","264.24","284.19","1 through 10","271.44","287.03","other","OPPS APC"
"MRI, Cerv Spine","PX-98301608","CDM","72141","CPT","0983","RC","","","","outpatient","","","377.00","282.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","291.16","287.06","291.16","1 through 10","188.5","764.88","other","OPPS APC"
"MRI, Cerv Spine Combo","PX-98301614","CDM","72156","CPT","0983","RC","","","","both","","","578.00","433.50","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","419.73","1015.16","1 through 10","416.16","424.07","other","OPPS APC"
"MRI, Cerv Spine Combo","PX-98301614","CDM","72156","CPT","0983","RC","","","","outpatient","","","578.00","433.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","1015.16","1015.16","1015.16","1 through 10","289","1200.44","other","OPPS APC"
"MRI, Dorsal Spine","PX-98301610","CDM","72146","CPT","0983","RC","","","","both","","","377.00","282.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","271.44","287.03","other","OPPS APC"
"MRI, Dorsal Spine","PX-98301610","CDM","72146","CPT","0983","RC","","","","both","","","377.00","282.75","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","1 through 10","271.44","287.03","other","OPPS APC"
"MRI, Dorsal Spine","PX-98301610","CDM","72146","CPT","0983","RC","","","","both","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","286.32","286.32","286.32","1 through 10","271.44","287.03","other","OPPS APC"
"MRI, Dorsal Spine Combo","PX-98301615","CDM","72157","CPT","0983","RC","","","","both","","","505.00","378.75","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","424.11","1015.16","1 through 10","363.6","424.07","other","OPPS APC"
"MRI, Face, Neck, Combo","PX-98301590","CDM","70543","CPT","0983","RC","","","","both","","","541.00","405.75","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","389.52","424.07","other","OPPS APC"
"MRI, Face, Neck, Combo","PX-98301590","CDM","70543","CPT","0983","RC","","","","both","","","541.00","405.75","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.87","419.87","419.87","1 through 10","389.52","424.07","other","OPPS APC"
"MRI, Joint Upper Extrem","PX-98301623","CDM","73221","CPT","0983","RC","","","","both","","","350.00","262.50","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","281.82","287.06","1 through 10","252","287.03","other","OPPS APC"
"MRI, Lumbar Spine","PX-98301612","CDM","72148","CPT","0983","RC","","","","both","","","328.00","246.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","236.16","287.03","other","OPPS APC"
"MRI, Lumbar Spine","PX-98301612","CDM","72148","CPT","0983","RC","","","","both","","","328.00","246.00","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","641.60","45","236.16","287.03","other","OPPS APC"
"MRI, Lumbar Spine","PX-98301612","CDM","72148","CPT","0983","RC","","","","both","","","328.00","246.00","MGB HEALTH PLAN [150001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","853.56","853.56","853.56","1 through 10","236.16","287.03","other","OPPS APC"
"MRI, Lumbar Spine","PX-98301612","CDM","72148","CPT","0983","RC","","","","both","","","328.00","246.00","UNITED HEALTHCARE [1016]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","286.32","262.30","633.77","1 through 10","236.16","287.03","other","OPPS APC"
"MRI, Lumbar Spine","PX-98301612","CDM","72148","CPT","0983","RC","","","","outpatient","","","328.00","246.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","176.17","53.71","","282.47","282.47","282.47","1 through 10","164","846","percent of total billed charges",""
"MRI, Lumbar Spine Combo","PX-98301616","CDM","72158","CPT","0983","RC","","","","both","","","505.00","378.75","MEDICARE [2001]","HB MCL MEDICARE","424.07","","APC Price ($424.07). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","848.22","419.73","1863.38","1 through 10","363.6","424.07","other","OPPS APC"
"MRI, Lumbar Spine|REDUCED SERVICES","PX-98301612","CDM","72148","CPT","0983","RC","","","52","both","","","328.00","246.00","MEDICARE [2001]","HB MCL MEDICARE","307.41","","APC Price ($307.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","307.41","307.41","other","OPPS APC"
"MRI, Pelvis, W/O Contrast","PX-98301618","CDM","72195","CPT","0983","RC","","","","both","","","370.00","277.50","MEDICARE [2001]","HB MCL MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","641.60","1 through 10","266.4","287.03","other","OPPS APC"
"MRI, Pelvis, W/O Contrast","PX-98301618","CDM","72195","CPT","0983","RC","","","","outpatient","","","370.00","277.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present.","284.12","203.70","284.12","1 through 10","185","1331","other","OPPS APC"
"Neurobehavioral Status Xm Phys/Qhp Ea Addl Hour","PX-90000134","CDM","96121","CPT","0918","RC","","","","outpatient","","","401.00","300.75","AETNA [1001]","HB MCL AETNA","221.75","55.3","","290.25","290.25","290.25","1 through 10","215.38","344","percent of total billed charges",""
"Neurobehavioral Status Xm Phys/Qhp Ea Addl Hour","PX-90000134","CDM","96121","CPT","0918","RC","","","","outpatient","","","401.00","300.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","240.60","60","","215.22","215.22","224.73","1 through 10","215.38","344","percent of total billed charges",""
"Neurobehavioral Status Xm Phys/Qhp Ea Addl Hour","PX-90000134","CDM","96121","CPT","0918","RC","","","","outpatient","","","401.00","300.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","215.38","53.71","","208.79","208.79","208.79","1 through 10","215.38","344","percent of total billed charges",""
"Neurobehavioral Status Xm Phys/Qhp Ea Addl Hour","PX-96000029","CDM","96121","CPT","0961","RC","","","","outpatient","","","123.00","92.25","AETNA [1001]","HB MCL AETNA","68.02","55.3","","290.25","290.25","290.25","1 through 10","66.06","344","percent of total billed charges",""
"Neurobehavioral Status Xm Phys/Qhp Ea Addl Hour","PX-96000029","CDM","96121","CPT","0961","RC","","","","outpatient","","","123.00","92.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","73.80","60","","215.22","215.22","224.73","1 through 10","66.06","344","percent of total billed charges",""
"Neurobehavioral Status Xm Phys/Qhp Ea Addl Hour","PX-96000029","CDM","96121","CPT","0961","RC","","","","outpatient","","","123.00","92.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","66.06","53.71","","208.79","208.79","208.79","1 through 10","66.06","344","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","both","","","546.00","409.50","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.79","101.71","161.70","1 through 10","393.12","393.12","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","both","","","546.00","409.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.56","107.56","107.56","1 through 10","393.12","393.12","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","both","","","546.00","409.50","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","107.12","107.12","1 through 10","393.12","393.12","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","both","","","546.00","409.50","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","409.89","819.78","32","393.12","393.12","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","both","","","546.00","409.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.35","109.31","111.00","62","393.12","393.12","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","outpatient","","","546.00","409.50","AETNA [1001]","HB MCL AETNA","301.94","55.3","","396.46","396.46","436.86","14","293.26","414.96","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","outpatient","","","546.00","409.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","327.60","60","","373.14","373.14","389.64","55","293.26","414.96","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","outpatient","","","546.00","409.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","293.26","53.71","","698.00","309.99","698.00","1 through 10","293.26","414.96","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-90000137","CDM","96132","CPT","0918","RC","","","","outpatient","","","546.00","409.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","49.25","49.25","109.31","12","293.26","414.96","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","both","","","169.00","126.75","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.79","101.71","161.70","1 through 10","121.68","121.68","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","both","","","169.00","126.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.56","107.56","107.56","1 through 10","121.68","121.68","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","both","","","169.00","126.75","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","107.12","107.12","1 through 10","121.68","121.68","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","both","","","169.00","126.75","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","409.89","819.78","32","121.68","121.68","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","both","","","169.00","126.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.35","109.31","111.00","62","121.68","121.68","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","outpatient","","","169.00","126.75","AETNA [1001]","HB MCL AETNA","93.46","55.3","","396.46","396.46","436.86","14","90.77","413.68","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","outpatient","","","169.00","126.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","101.40","60","","373.14","373.14","389.64","55","90.77","413.68","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","outpatient","","","169.00","126.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","90.77","53.71","","698.00","309.99","698.00","1 through 10","90.77","413.68","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp 1st Hour","PX-96000032","CDM","96132","CPT","0961","RC","","","","outpatient","","","169.00","126.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","49.25","49.25","109.31","12","90.77","413.68","other","OPPS APC"
"Neuropsychological Tst Eval Phys/Qhp Ea Addl Hr","PX-90000138","CDM","96133","CPT","0918","RC","","","","outpatient","","","419.00","314.25","AETNA [1001]","HB MCL AETNA","231.71","55.3","","303.88","303.88","303.88","46","225.04","344","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp Ea Addl Hr","PX-90000138","CDM","96133","CPT","0918","RC","","","","outpatient","","","419.00","314.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","251.40","60","","297.20","284.61","297.20","185","225.04","344","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp Ea Addl Hr","PX-90000138","CDM","96133","CPT","0918","RC","","","","outpatient","","","419.00","314.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","225.04","53.71","","535.00","285.69","535.00","33","225.04","344","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp Ea Addl Hr","PX-96000033","CDM","96133","CPT","0961","RC","","","","outpatient","","","129.00","96.75","AETNA [1001]","HB MCL AETNA","71.34","55.3","","303.88","303.88","303.88","46","69.29","344","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp Ea Addl Hr","PX-96000033","CDM","96133","CPT","0961","RC","","","","outpatient","","","129.00","96.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","77.40","60","","297.20","284.61","297.20","185","69.29","344","percent of total billed charges",""
"Neuropsychological Tst Eval Phys/Qhp Ea Addl Hr","PX-96000033","CDM","96133","CPT","0961","RC","","","","outpatient","","","129.00","96.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","69.29","53.71","","535.00","285.69","535.00","33","69.29","344","percent of total billed charges",""
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","32731.00","24548.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","1118.22","","Case rate ($1,118.22) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","572.51","164.28","11486.34","1 through 10","1118.22","1118.22","other","Inpatient Psych"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","32731.00","24548.25","ELDER SERVICES [1037]","HB MCL MEDICARE","1118.22","","Case rate ($1,118.22) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","116.40","116.40","1767.04","1 through 10","1118.22","1118.22","other","Inpatient Psych"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","32731.00","24548.25","MEDICARE [2001]","HB MCL MEDICARE","1118.22","","Case rate ($1,118.22) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16915.18","9376.38","55516.99","1 through 10","1118.22","1118.22","other","Inpatient Psych"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","32731.00","24548.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1118.22","","Case rate ($1,118.22) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","164.32","105.02","881.64","12","1118.22","1118.22","other","Inpatient Psych"
"Ocd Transcranial Magnetic Stimulation Treatment,Delivery/Mgmt","PX-96100063","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","AETNA [1001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.53","276.97","381.33","24","213.12","369.77","other","OPPS APC"
"Ocd Transcranial Magnetic Stimulation Treatment,Delivery/Mgmt","PX-96100063","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","216.98","363.89","66","213.12","369.77","other","OPPS APC"
"Ocd Transcranial Magnetic Stimulation Treatment,Delivery/Mgmt","PX-96100063","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","515","213.12","369.77","other","OPPS APC"
"Ocd Transcranial Magnetic Stimulation Treatment,Delivery/Mgmt","PX-96100063","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","221.41","221.41","221.50","631","213.12","369.77","other","OPPS APC"
"Ocd Transcranial Magnetic Stimulation Treatment,Delivery/Mgmt","PX-96100063","CDM","90868","CPT","0961","RC","","","","outpatient","","","296.00","222.00","AETNA [1001]","HB MCL AETNA","163.69","55.3","","428.84","428.84","499.06","106","158.98","595","percent of total billed charges",""
"Ocd Transcranial Magnetic Stimulation Treatment,Delivery/Mgmt","PX-96100063","CDM","90868","CPT","0961","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","158.98","53.71","","727.78","271.03","727.78","34","158.98","595","percent of total billed charges",""
"Ocd Transcranial Magnetic Stimulation Treatment,Delivery/Mgmt","PX-96100063","CDM","90868","CPT","0961","RC","","","","outpatient","","","296.00","222.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","297.64","297.64","297.64","43","158.98","595","other","OPPS APC"
"Ocd Transcranial Magnetic Stimulation Treatment,Planning","PX-96100062","CDM","90867","CPT","0961","RC","","","","both","","","879.00","659.25","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","632.88","other","OPPS APC"
"Ocd Transcranial Magnetic Stimulation Treatment,Planning","PX-96100062","CDM","90867","CPT","0961","RC","","","","both","","","879.00","659.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.97","380.97","381.12","17","369.77","632.88","other","OPPS APC"
"Ocd Transcranial Magnetic Stimulation Treatment,Planning","PX-96100062","CDM","90867","CPT","0961","RC","","","","outpatient","","","879.00","659.25","AETNA [1001]","HB MCL AETNA","486.09","55.3","","942.88","942.88","942.88","1 through 10","344","1023.79","percent of total billed charges",""
"Ocd Transcranial Magnetic Stimulation Treatment,Planning","PX-96100062","CDM","90867","CPT","0961","RC","","","","outpatient","","","879.00","659.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","348.62","348.62","348.62","1 through 10","344","1023.79","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","516.00","387.00","AETNA [1001]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","89.23","210.65","15","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","516.00","387.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.47","125.47","151.80","1 through 10","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","516.00","387.00","ELDER SERVICES [1037]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.43","134.43","134.43","1 through 10","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","516.00","387.00","HUMANA [1012]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","148.21","147.01","148.21","1 through 10","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","516.00","387.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.01","127.51","150.07","182","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","516.00","387.00","AETNA [1001]","HB MCL AETNA","285.35","55.3","","281.61","281.61","563.22","62","40.47","550.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","516.00","387.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present.","150.01","150.01","450.03","25","40.47","550.57","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","516.00","387.00","AETNA [1001]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","89.23","210.65","15","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","516.00","387.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.47","125.47","151.80","1 through 10","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","516.00","387.00","ELDER SERVICES [1037]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.43","134.43","134.43","1 through 10","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","516.00","387.00","HUMANA [1012]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","148.21","147.01","148.21","1 through 10","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","516.00","387.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.01","127.51","150.07","182","153.03","371.52","other","OPPS APC"
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","516.00","387.00","AETNA [1001]","HB MCL AETNA","285.35","55.3","","281.61","281.61","563.22","62","153.03","550.57","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","516.00","387.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present.","150.01","150.01","450.03","25","153.03","550.57","other","OPPS APC"
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","281.00","210.75","AETNA [1001]","HB MCL AETNA","155.39","55.3","","123.24","123.24","246.48","97","68.78","344","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100047","CDM","99213","CPT","0961","RC","","","","outpatient","","","281.00","210.75","MASSHEALTH [3001]","HB MCL MEDICAID","182.09","64.8","","144.50","144.50","144.50","1 through 10","68.78","344","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","outpatient","","","415.00","311.25","AETNA [1001]","HB MCL AETNA","229.50","55.3","","195.24","195.24","390.48","66","101.19","392.53","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100048","CDM","99214","CPT","0961","RC","","","","outpatient","","","415.00","311.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","222.90","53.71","","405.00","405.00","405.00","1 through 10","101.19","392.53","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","580.00","435.00","AETNA [1001]","HB MCL AETNA","320.74","55.3","","281.61","281.61","563.22","62","150.01","550.57","percent of total billed charges",""
"Opps/Php/Iop; Train & Educ Serv","PX-90000021","CDM","G0177","HCPCS","0915","RC","","","","outpatient","","","179.00","134.25","BLUE CROSS ALTERNATE [110002]","HB MCL BLUE CROSS HMO / PPO / INDEM","107.40","60","","175.00","175.00","175.00","1 through 10","96.14","344","percent of total billed charges",""
"Opps/Php/Iop; Train & Educ Serv","PX-90000021","CDM","G0177","HCPCS","0915","RC","","","","outpatient","","","179.00","134.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","96.14","53.71","","119.19","119.19","119.19","48","96.14","344","percent of total billed charges",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","15583.00","11687.25","MEDICARE [2001]","HB MCL MEDICARE","1184.00","","Case rate ($1,184.00) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","54013.24","54013.24","54013.24","1 through 10","1184","1184","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","15583.00","11687.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1184.00","","Case rate ($1,184.00) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","436.63","263.85","1391.40","1 through 10","1184","1184","other","Inpatient Psych"
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","both","","","134.00","100.50","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","500.05","128.38","500.05","1 through 10","96.48","96.48","other","OPPS APC"
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","both","","","134.00","100.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.22","80.06","477.22","1 through 10","96.48","96.48","other","OPPS APC"
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","both","","","134.00","100.50","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.03","81.03","81.03","1 through 10","96.48","96.48","other","OPPS APC"
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","both","","","134.00","100.50","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","409.89","485.18","37","96.48","96.48","other","OPPS APC"
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","both","","","134.00","100.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.39","81.36","84.03","17","96.48","96.48","other","OPPS APC"
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","outpatient","","","134.00","100.50","AETNA [1001]","HB MCL AETNA","74.10","55.3","","355.50","299.61","355.50","1 through 10","71.97","344","percent of total billed charges",""
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","outpatient","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","71.97","53.71","","233.36","233.36","254.16","1 through 10","71.97","344","percent of total billed charges",""
"Pf Exam Neurobehavrl by Psych / Hr","PX-96100012","CDM","96116","CPT","0961","RC","","","","outpatient","","","134.00","100.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","252.09","82.95","348.62","11","71.97","344","other","OPPS APC"
"Pf Psy Thrpy Family W/O Pt","PX-96100001","CDM","90846","CPT","0961","RC","","","","both","","","340.00","255.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.69","102.69","102.69","1 through 10","244.8","244.8","other","OPPS APC"
"Pf Psy Thrpy Family W/O Pt","PX-96100001","CDM","90846","CPT","0961","RC","","","","outpatient","","","340.00","255.00","AETNA [1001]","HB MCL AETNA","188.02","55.3","","572.24","513.12","572.24","1 through 10","182.61","344","percent of total billed charges",""
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","both","","","355.00","266.25","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","72.52","72.52","72.52","1 through 10","255.6","255.6","other","OPPS APC"
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","both","","","355.00","266.25","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1038.24","262.28","1038.24","1 through 10","255.6","255.6","other","OPPS APC"
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","both","","","355.00","266.25","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","819.78","35","255.6","255.6","other","OPPS APC"
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","both","","","355.00","266.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.34","81.31","107.83","18","255.6","255.6","other","OPPS APC"
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","outpatient","","","355.00","266.25","AETNA [1001]","HB MCL AETNA","196.32","55.3","","618.00","618.00","682.00","33","186.2","355.67","percent of total billed charges",""
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","outpatient","","","355.00","266.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","190.67","53.71","","186.50","186.50","186.50","1 through 10","186.2","355.67","percent of total billed charges",""
"Pf Psy Thrpy Family W/Pt","PX-96100002","CDM","90847","CPT","0961","RC","","","","outpatient","","","355.00","266.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","106.29","80.22","186.99","1 through 10","186.2","355.67","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.62","48.62","113.83","87","69.12","69.12","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","96.00","72.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.17","24.89","108.09","190","69.12","69.12","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","96.00","72.00","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.22","25.07","108.31","18","69.12","69.12","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","96.00","72.00","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","449","69.12","69.12","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","96.00","72.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.59","21.61","25.59","879","69.12","69.12","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","96.00","72.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.29","25.29","25.29","1 through 10","69.12","69.12","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","outpatient","","","96.00","72.00","AETNA [1001]","HB MCL AETNA","53.09","55.3","","208.74","208.74","208.74","259","51.56","344","percent of total billed charges",""
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","outpatient","","","96.00","72.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","51.56","53.71","","216.18","119.19","216.18","86","51.56","344","percent of total billed charges",""
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","outpatient","","","96.00","72.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","25.08","15.63","25.58","160","51.56","344","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","618.00","463.50","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.14","185.03","222.13","27","444.96","444.96","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","618.00","463.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","171.23","145.11","187.76","49","444.96","444.96","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","618.00","463.50","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","172.87","170.02","355.95","1 through 10","444.96","444.96","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","618.00","463.50","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","171","444.96","444.96","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","618.00","463.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","173.56","147.47","173.56","284","444.96","444.96","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","outpatient","","","618.00","463.50","AETNA [1001]","HB MCL AETNA","341.75","55.3","","547.55","547.55","547.55","47","206.68","583.38","percent of total billed charges",""
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","outpatient","","","618.00","463.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","331.93","53.71","","670.19","603.00","670.19","25","206.68","583.38","percent of total billed charges",""
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","outpatient","","","618.00","463.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","170.11","27.84","173.49","27","206.68","583.38","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","550.00","412.50","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.14","193.23","500.05","13","396","396","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","550.00","412.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","111.37","189.45","17","396","396","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","550.00","412.50","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","1229.67","72","396","396","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","550.00","412.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.96","113.23","150.96","55","396","396","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB MCL AETNA","304.15","55.3","","503.82","503.82","503.82","52","206.68","518.86","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","550.00","412.50","AETNA [1001]","HB MCL AETNA STUDENT HEALTH","304.15","55.3","","503.82","503.82","503.82","1 through 10","206.68","518.86","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","550.00","412.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","295.41","53.71","","203.56","186.90","887.00","1 through 10","206.68","518.86","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","550.00","412.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","113.18","27.84","186.99","18","206.68","518.86","other","OPPS APC"
"Psych - Prolonged Outpatient E/M Service Each 15 Minutes","PX-96000059","CDM","99417","CPT","0961","RC","","","","outpatient","","","128.00","96.00","AETNA [1001]","HB MCL AETNA","70.78","55.3","","76.68","76.68","76.68","1 through 10","68.75","344","percent of total billed charges",""
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","370.00","277.50","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.14","185.03","222.13","27","266.4","266.4","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","370.00","277.50","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","171.23","145.11","187.76","49","266.4","266.4","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","370.00","277.50","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","172.87","170.02","355.95","1 through 10","266.4","266.4","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","370.00","277.50","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","190.81","171","266.4","266.4","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","370.00","277.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","173.56","147.47","173.56","284","266.4","266.4","other","OPPS APC"
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","outpatient","","","370.00","277.50","AETNA [1001]","HB MCL AETNA","204.61","55.3","","547.55","547.55","547.55","47","198.73","583.38","percent of total billed charges",""
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","outpatient","","","370.00","277.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","198.73","53.71","","670.19","603.00","670.19","25","198.73","583.38","percent of total billed charges",""
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","outpatient","","","370.00","277.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","170.11","27.84","173.49","27","198.73","583.38","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","229.00","171.75","AETNA [1001]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.12","108.12","110.33","1 through 10","153.03","164.88","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","229.00","171.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.25","57.52","69.25","1 through 10","153.03","164.88","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","both","","","229.00","171.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","68.81","68.78","68.81","122","153.03","164.88","other","OPPS APC"
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","229.00","171.75","AETNA [1001]","HB MCL AETNA","126.64","55.3","","123.24","123.24","246.48","97","123","344","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","229.00","171.75","MASSHEALTH [3001]","HB MCL MEDICAID","148.39","64.8","","144.50","144.50","144.50","1 through 10","123","344","percent of total billed charges",""
"Psych Est Patient (99213) - Medium Level (16-45 Min)","PX-90000101","CDM","99213","CPT","0914","RC","","","","outpatient","","","229.00","171.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","153.03","","APC Price ($153.03). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present.","68.78","68.78","68.78","1 through 10","123","344","other","OPPS APC"
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","117.00","87.75","AETNA [1001]","HB MCL AETNA","64.70","55.3","","25.17","25.17","25.17","12","62.84","344","percent of total billed charges",""
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","175.00","131.25","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.62","48.62","113.83","87","126","126","other","OPPS APC"
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","175.00","131.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.17","24.89","108.09","190","126","126","other","OPPS APC"
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","175.00","131.25","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.22","25.07","108.31","18","126","126","other","OPPS APC"
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","175.00","131.25","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.85","109.85","109.85","449","126","126","other","OPPS APC"
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","175.00","131.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.59","21.61","25.59","879","126","126","other","OPPS APC"
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","175.00","131.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.29","25.29","25.29","1 through 10","126","126","other","OPPS APC"
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","outpatient","","","175.00","131.25","AETNA [1001]","HB MCL AETNA","96.78","55.3","","208.74","208.74","208.74","259","87.98","344","percent of total billed charges",""
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","outpatient","","","175.00","131.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","93.99","53.71","","216.18","119.19","216.18","86","87.98","344","percent of total billed charges",""
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","outpatient","","","175.00","131.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","25.08","15.63","25.58","160","87.98","344","other","OPPS APC"
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-90000184","CDM","98013","CPT","0914","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB MCL AETNA","130.51","55.3","","140.86","140.86","140.86","1 through 10","126.76","344","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-96000079","CDM","98013","CPT","0961","RC","","","","outpatient","","","248.00","186.00","AETNA [1001]","HB MCL AETNA","137.14","55.3","","140.86","140.86","140.86","1 through 10","133.2","344","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-90000185","CDM","98014","CPT","0914","RC","","","","outpatient","","","367.00","275.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","220.20","60","","236.49","236.49","236.49","1 through 10","197.12","344","percent of total billed charges",""
"Psych Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-96000080","CDM","98014","CPT","0961","RC","","","","outpatient","","","367.00","275.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","220.20","60","","236.49","236.49","236.49","1 through 10","197.12","344","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-90000176","CDM","98005","CPT","0914","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB MCL AETNA","130.51","55.3","","153.36","153.36","153.36","19","126.76","344","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-96000071","CDM","98005","CPT","0961","RC","","","","outpatient","","","270.00","202.50","AETNA [1001]","HB MCL AETNA","149.31","55.3","","153.36","153.36","153.36","19","145.02","344","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-90000177","CDM","98006","CPT","0914","RC","","","","outpatient","","","367.00","275.25","AETNA [1001]","HB MCL AETNA","202.95","55.3","","227.77","227.77","227.77","56","197.12","344","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-96000072","CDM","98006","CPT","0961","RC","","","","outpatient","","","401.00","300.75","AETNA [1001]","HB MCL AETNA","221.75","55.3","","227.77","227.77","227.77","56","215.38","344","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-90000173","CDM","98002","CPT","0914","RC","","","","outpatient","","","599.00","449.25","AETNA [1001]","HB MCL AETNA","331.25","55.3","","307.86","307.86","307.86","1 through 10","321.72","455.24","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-96000068","CDM","98002","CPT","0961","RC","","","","outpatient","","","542.00","406.50","AETNA [1001]","HB MCL AETNA","299.73","55.3","","307.86","307.86","307.86","1 through 10","291.11","411.92","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Sf Mdm 15 Min","PX-90000171","CDM","98000","CPT","0914","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB MCL AETNA","129.40","55.3","","110.19","110.19","110.19","1 through 10","125.68","344","percent of total billed charges",""
"Psych Synchronous Audio-Video Visit New Sf Mdm 15 Min","PX-96000066","CDM","98000","CPT","0961","RC","","","","outpatient","","","194.00","145.50","AETNA [1001]","HB MCL AETNA","107.28","55.3","","110.19","110.19","110.19","1 through 10","104.2","344","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-90000178","CDM","98007","CPT","0914","RC","","","","outpatient","","","516.00","387.00","AETNA [1001]","HB MCL AETNA","285.35","55.3","","307.86","307.86","307.86","71","277.14","392.16","percent of total billed charges",""
"Psych Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-96000073","CDM","98007","CPT","0961","RC","","","","outpatient","","","542.00","406.50","AETNA [1001]","HB MCL AETNA","299.73","55.3","","307.86","307.86","307.86","71","291.11","411.92","percent of total billed charges",""
"Psych Therapy Family W/O Pt","PX-90000024","CDM","90846","CPT","0916","RC","","","","both","","","233.00","174.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.69","102.69","102.69","1 through 10","167.76","167.76","other","OPPS APC"
"Psych Therapy Family W/O Pt","PX-90000024","CDM","90846","CPT","0916","RC","","","","outpatient","","","233.00","174.75","AETNA [1001]","HB MCL AETNA","128.85","55.3","","572.24","513.12","572.24","1 through 10","125.14","344","percent of total billed charges",""
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","both","","","279.00","209.25","ELDER SERVICES [1037]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","72.52","72.52","72.52","1 through 10","200.88","200.88","other","OPPS APC"
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","both","","","279.00","209.25","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1038.24","262.28","1038.24","1 through 10","200.88","200.88","other","OPPS APC"
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","both","","","279.00","209.25","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","819.78","35","200.88","200.88","other","OPPS APC"
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","both","","","279.00","209.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.34","81.31","107.83","18","200.88","200.88","other","OPPS APC"
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","outpatient","","","279.00","209.25","AETNA [1001]","HB MCL AETNA","154.29","55.3","","618.00","618.00","682.00","33","149.85","355.67","percent of total billed charges",""
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","outpatient","","","279.00","209.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","149.85","53.71","","186.50","186.50","186.50","1 through 10","149.85","355.67","percent of total billed charges",""
"Psych Therapy Family W/Pt","PX-90000025","CDM","90847","CPT","0916","RC","","","","outpatient","","","279.00","209.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","106.29","80.22","186.99","1 through 10","149.85","355.67","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","359.00","269.25","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","197.14","193.23","500.05","13","258.48","258.48","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","359.00","269.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.76","111.37","189.45","17","258.48","258.48","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","359.00","269.25","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","190.81","190.81","1229.67","72","258.48","258.48","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","359.00","269.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.96","113.23","150.96","55","258.48","258.48","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","359.00","269.25","AETNA [1001]","HB MCL AETNA","198.53","55.3","","503.82","503.82","503.82","52","192.82","518.86","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","359.00","269.25","AETNA [1001]","HB MCL AETNA STUDENT HEALTH","198.53","55.3","","503.82","503.82","503.82","1 through 10","192.82","518.86","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","359.00","269.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","192.82","53.71","","203.56","186.90","887.00","1 through 10","192.82","518.86","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","outpatient","","","359.00","269.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","113.18","27.84","186.99","18","192.82","518.86","other","OPPS APC"
"Psychological Tst Eval Svc Phys/Qhp Ea Addl Hour","PX-90000136","CDM","96131","CPT","0918","RC","","","","outpatient","","","425.00","318.75","AETNA [1001]","HB MCL AETNA","235.03","55.3","","308.42","308.42","308.43","24","228.27","344","percent of total billed charges",""
"Psychological Tst Eval Svc Phys/Qhp Ea Addl Hour","PX-96000031","CDM","96131","CPT","0961","RC","","","","outpatient","","","131.00","98.25","AETNA [1001]","HB MCL AETNA","72.44","55.3","","308.42","308.42","308.43","24","70.36","344","percent of total billed charges",""
"Psychological Tst Eval Svc Phys/Qhp First Hour","PX-90000135","CDM","96130","CPT","0918","RC","","","","both","","","559.00","419.25","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","485.18","1 through 10","402.48","402.48","other","OPPS APC"
"Psychological Tst Eval Svc Phys/Qhp First Hour","PX-90000135","CDM","96130","CPT","0918","RC","","","","both","","","559.00","419.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","112.94","112.94","112.94","1 through 10","402.48","402.48","other","OPPS APC"
"Psychological Tst Eval Svc Phys/Qhp First Hour","PX-90000135","CDM","96130","CPT","0918","RC","","","","outpatient","","","559.00","419.25","AETNA [1001]","HB MCL AETNA","309.13","55.3","","404.98","404.98","404.98","1 through 10","300.24","424.84","percent of total billed charges",""
"Psychological Tst Eval Svc Phys/Qhp First Hour","PX-96000030","CDM","96130","CPT","0961","RC","","","","both","","","172.00","129.00","MEDICARE [2001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","485.18","1 through 10","123.84","123.84","other","OPPS APC"
"Psychological Tst Eval Svc Phys/Qhp First Hour","PX-96000030","CDM","96130","CPT","0961","RC","","","","both","","","172.00","129.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","112.94","112.94","112.94","1 through 10","123.84","123.84","other","OPPS APC"
"Psychological Tst Eval Svc Phys/Qhp First Hour","PX-96000030","CDM","96130","CPT","0961","RC","","","","outpatient","","","172.00","129.00","AETNA [1001]","HB MCL AETNA","95.12","55.3","","404.98","404.98","404.98","1 through 10","92.38","365.59","percent of total billed charges",""
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","AETNA [1001]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","13497.31","391.30","15499.43","1 through 10","1096.3","1096.3","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","291.28","82.14","12882.86","107","1096.3","1096.3","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","ELDER SERVICES [1037]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","984.26","291.48","41160.00","1 through 10","1096.3","1096.3","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","GENERIC MEDICARE REPLACEMENT [1010]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","1060.33","167.64","28051.91","1 through 10","1096.3","1096.3","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","HUMANA [1012]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","492.82","153.65","50488.65","1 through 10","1096.3","1096.3","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","MEDICARE [2001]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","6747.45","46.25","81378.22","57","1096.3","1096.3","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","211.08","85.41","1545.39","164","1096.3","1096.3","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","32844.00","24633.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICARE","1096.30","","Case rate ($1,096.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $48,327.62 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.453, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16; Intensive Management for High-Risk Behavior: 1.07. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","740.60","83.82","47995.06","30","1096.3","1096.3","other","Inpatient Psych"
"Psycl/Nrpsycl Tst Phys/Qhp 2+ Tst Ea Addl 30 Min","PX-90000140","CDM","96137","CPT","0918","RC","","","","outpatient","","","98.00","73.50","AETNA [1001]","HB MCL AETNA","54.19","55.3","","71.57","71.57","71.57","84","52.64","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Phys/Qhp 2+ Tst Ea Addl 30 Min","PX-90000140","CDM","96137","CPT","0918","RC","","","","outpatient","","","98.00","73.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","58.80","60","","96.00","96.00","96.00","409","52.64","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Phys/Qhp 2+ Tst Ea Addl 30 Min","PX-90000140","CDM","96137","CPT","0918","RC","","","","outpatient","","","98.00","73.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","52.64","53.71","","51.26","51.26","55.83","27","52.64","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Phys/Qhp 2+ Tst Ea Addl 30 Min","PX-96000035","CDM","96137","CPT","0961","RC","","","","outpatient","","","31.00","23.25","AETNA [1001]","HB MCL AETNA","17.14","55.3","","71.57","71.57","71.57","84","16.65","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Phys/Qhp 2+ Tst Ea Addl 30 Min","PX-96000035","CDM","96137","CPT","0961","RC","","","","outpatient","","","31.00","23.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","18.60","60","","96.00","96.00","96.00","409","16.65","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Phys/Qhp 2+ Tst Ea Addl 30 Min","PX-96000035","CDM","96137","CPT","0961","RC","","","","outpatient","","","31.00","23.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","16.65","53.71","","51.26","51.26","55.83","27","16.65","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-90000141","CDM","96138","CPT","0918","RC","","","","outpatient","","","217.00","162.75","AETNA [1001]","HB MCL AETNA","120.00","55.3","","132.69","120.42","132.69","1 through 10","116.55","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-90000141","CDM","96138","CPT","0918","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","130.20","60","","108.30","108.30","212.00","1 through 10","116.55","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-90000141","CDM","96138","CPT","0918","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","116.55","53.71","","113.21","113.21","113.21","1 through 10","116.55","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-90000141","CDM","96138","CPT","0918","RC","","","","outpatient","","","217.00","162.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","49.25","49.25","49.25","1 through 10","116.55","344","other","OPPS APC"
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-96000036","CDM","96138","CPT","0961","RC","","","","outpatient","","","60.00","45.00","AETNA [1001]","HB MCL AETNA","33.18","55.3","","132.69","120.42","132.69","1 through 10","32.23","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-96000036","CDM","96138","CPT","0961","RC","","","","outpatient","","","60.00","45.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","36.00","60","","108.30","108.30","212.00","1 through 10","32.23","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-96000036","CDM","96138","CPT","0961","RC","","","","outpatient","","","60.00","45.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","32.23","53.71","","113.21","113.21","113.21","1 through 10","32.23","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst 1st 30 Min","PX-96000036","CDM","96138","CPT","0961","RC","","","","outpatient","","","60.00","45.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","49.25","49.25","49.25","1 through 10","32.23","344","other","OPPS APC"
"Psycl/Nrpsycl Tst Tech 2+ Tst Ea Addl 30 Min","PX-90000142","CDM","96139","CPT","0918","RC","","","","outpatient","","","217.00","162.75","AETNA [1001]","HB MCL AETNA","120.00","55.3","","120.42","120.42","1061.49","1 through 10","116.55","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst Ea Addl 30 Min","PX-90000142","CDM","96139","CPT","0918","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","130.20","60","","111.49","108.00","116.42","76","116.55","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst Ea Addl 30 Min","PX-90000142","CDM","96139","CPT","0918","RC","","","","outpatient","","","217.00","162.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","116.55","53.71","","113.21","113.21","113.21","1 through 10","116.55","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst Ea Addl 30 Min","PX-96000037","CDM","96139","CPT","0961","RC","","","","outpatient","","","60.00","45.00","AETNA [1001]","HB MCL AETNA","33.18","55.3","","120.42","120.42","1061.49","1 through 10","32.23","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst Ea Addl 30 Min","PX-96000037","CDM","96139","CPT","0961","RC","","","","outpatient","","","60.00","45.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","36.00","60","","111.49","108.00","116.42","76","32.23","344","percent of total billed charges",""
"Psycl/Nrpsycl Tst Tech 2+ Tst Ea Addl 30 Min","PX-96000037","CDM","96139","CPT","0961","RC","","","","outpatient","","","60.00","45.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","32.23","53.71","","113.21","113.21","113.21","1 through 10","32.23","344","percent of total billed charges",""
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","both","","","127.00","95.25","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.57","23.57","23.57","1 through 10","91.44","91.44","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","both","","","127.00","95.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.67","23.67","23.67","1 through 10","91.44","91.44","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","both","","","127.00","95.25","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.57","23.57","23.57","1 through 10","91.44","91.44","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","both","","","127.00","95.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24.06","24.06","24.45","21","91.44","91.44","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","outpatient","","","127.00","95.25","AETNA [1001]","HB MCL AETNA","70.23","55.3","","92.01","92.01","92.01","11","68.21","344","percent of total billed charges",""
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","outpatient","","","127.00","95.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","76.20","60","","124.00","124.00","124.00","65","68.21","344","percent of total billed charges",""
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","outpatient","","","127.00","95.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","68.21","53.71","","66.22","66.22","72.12","1 through 10","68.21","344","percent of total billed charges",""
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-90000139","CDM","96136","CPT","0918","RC","","","","outpatient","","","127.00","95.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","49.25","24.05","49.25","1 through 10","68.21","344","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","both","","","39.00","29.25","AETNA [1001]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.57","23.57","23.57","1 through 10","28.08","28.08","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","both","","","39.00","29.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.67","23.67","23.67","1 through 10","28.08","28.08","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","both","","","39.00","29.25","HUMANA [1012]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.57","23.57","23.57","1 through 10","28.08","28.08","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","both","","","39.00","29.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24.06","24.06","24.45","21","28.08","28.08","other","OPPS APC"
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","outpatient","","","39.00","29.25","AETNA [1001]","HB MCL AETNA","21.57","55.3","","92.01","92.01","92.01","11","20.95","344","percent of total billed charges",""
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","outpatient","","","39.00","29.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","23.40","60","","124.00","124.00","124.00","65","20.95","344","percent of total billed charges",""
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","outpatient","","","39.00","29.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","20.95","53.71","","66.22","66.22","72.12","1 through 10","20.95","344","percent of total billed charges",""
"Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1st 30 Min","PX-96000034","CDM","96136","CPT","0961","RC","","","","outpatient","","","39.00","29.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.65), quantity 4 or more, Per diem ($485.13). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.09), quantity 4 or more, Per diem ($199.87).","49.25","24.05","49.25","1 through 10","20.95","344","other","OPPS APC"
"Repet Ocd Tms Tx Initial W/Map/Motr Threshld/Del&M","PX-99900338","CDM","90867","CPT","0900","RC","","","","both","","","822.00","616.50","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","591.84","other","OPPS APC"
"Repet Ocd Tms Tx Initial W/Map/Motr Threshld/Del&M","PX-99900338","CDM","90867","CPT","0900","RC","","","","both","","","822.00","616.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.97","380.97","381.12","17","369.77","591.84","other","OPPS APC"
"Repet Ocd Tms Tx Initial W/Map/Motr Threshld/Del&M","PX-99900338","CDM","90867","CPT","0900","RC","","","","outpatient","","","822.00","616.50","AETNA [1001]","HB MCL AETNA","454.57","55.3","","942.88","942.88","942.88","1 through 10","369.77","1023.79","percent of total billed charges",""
"Repet Ocd Tms Tx Initial W/Map/Motr Threshld/Del&M","PX-99900338","CDM","90867","CPT","0900","RC","","","","outpatient","","","822.00","616.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","348.62","348.62","348.62","1 through 10","369.77","1023.79","other","OPPS APC"
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mn","PX-99900340","CDM","90869","CPT","0900","RC","","","","both","","","610.00","457.50","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","439.2","other","OPPS APC"
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mn","PX-99900340","CDM","90869","CPT","0900","RC","","","","both","","","610.00","457.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.32","319.32","319.45","16","369.77","439.2","other","OPPS APC"
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mn","PX-99900340","CDM","90869","CPT","0900","RC","","","","outpatient","","","610.00","457.50","AETNA [1001]","HB MCL AETNA","337.33","55.3","","900.28","900.28","900.28","1 through 10","305","858.14","percent of total billed charges",""
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mn","PX-99900340","CDM","90869","CPT","0900","RC","","","","outpatient","","","610.00","457.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","287.50","287.50","287.50","1 through 10","305","858.14","other","OPPS APC"
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100064","CDM","90869","CPT","0961","RC","","","","both","","","914.00","685.50","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","658.08","other","OPPS APC"
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100064","CDM","90869","CPT","0961","RC","","","","both","","","914.00","685.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.32","319.32","319.45","16","369.77","658.08","other","OPPS APC"
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100064","CDM","90869","CPT","0961","RC","","","","outpatient","","","914.00","685.50","AETNA [1001]","HB MCL AETNA","505.44","55.3","","900.28","900.28","900.28","1 through 10","306.5","858.14","percent of total billed charges",""
"Repet Ocd Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100064","CDM","90869","CPT","0961","RC","","","","outpatient","","","914.00","685.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","287.50","287.50","287.50","1 through 10","306.5","858.14","other","OPPS APC"
"Repet Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100061","CDM","90869","CPT","0961","RC","","","","both","","","914.00","685.50","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","658.08","other","OPPS APC"
"Repet Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100061","CDM","90869","CPT","0961","RC","","","","both","","","914.00","685.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.32","319.32","319.45","16","369.77","658.08","other","OPPS APC"
"Repet Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100061","CDM","90869","CPT","0961","RC","","","","outpatient","","","914.00","685.50","AETNA [1001]","HB MCL AETNA","505.44","55.3","","900.28","900.28","900.28","1 through 10","306.5","858.14","percent of total billed charges",""
"Repet Tms Tx Subseq Motr Threshld W/Deliv & Mngt","PX-96100061","CDM","90869","CPT","0961","RC","","","","outpatient","","","914.00","685.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","287.50","287.50","287.50","1 through 10","306.5","858.14","other","OPPS APC"
"Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Minutes","PX-98300814","CDM","99231","CPT","0961","RC","","","","outpatient","","","62.00","46.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","33.30","53.71","","60.00","60.00","60.00","1 through 10","33.3","1287.8","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Low Mdm 20 Min","PX-51000664","CDM","98013","CPT","0510","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB MCL AETNA","130.51","55.3","","140.86","140.86","140.86","1 through 10","118","179.36","percent of total billed charges",""
"Synchronous Audio-Only Visit Est Mod Mdm 30 Min","PX-51000665","CDM","98014","CPT","0510","RC","","","","outpatient","","","367.00","275.25","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS HMO / PPO / INDEM","220.20","60","","236.49","236.49","236.49","1 through 10","183.5","278.92","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Low Mdm 20 Min","PX-51000656","CDM","98005","CPT","0510","RC","","","","outpatient","","","236.00","177.00","AETNA [1001]","HB MCL AETNA","130.51","55.3","","153.36","153.36","153.36","19","118","179.36","percent of total billed charges",""
"Synchronous Audio-Video Visit Est Mod Mdm 30 Min","PX-51000657","CDM","98006","CPT","0510","RC","","","","outpatient","","","367.00","275.25","AETNA [1001]","HB MCL AETNA","202.95","55.3","","227.77","227.77","227.77","56","183.5","278.92","percent of total billed charges",""
"Synchronous Audio-Video Visit New Mod Mdm 45 Min","PX-51000653","CDM","98002","CPT","0510","RC","","","","outpatient","","","599.00","449.25","AETNA [1001]","HB MCL AETNA","331.25","55.3","","307.86","307.86","307.86","1 through 10","299.5","455.24","percent of total billed charges",""
"Synchronous Audio-Video Visit New Sf Mdm 15 Min","PX-51000651","CDM","98000","CPT","0510","RC","","","","outpatient","","","234.00","175.50","AETNA [1001]","HB MCL AETNA","129.40","55.3","","110.19","110.19","110.19","1 through 10","117","177.84","percent of total billed charges",""
"Synchronous Audio-Video Vst Est High Mdm 40 Min","PX-51000658","CDM","98007","CPT","0510","RC","","","","outpatient","","","516.00","387.00","AETNA [1001]","HB MCL AETNA","285.35","55.3","","307.86","307.86","307.86","71","258","392.16","percent of total billed charges",""
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","AETNA [1001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.53","276.97","381.33","24","352.08","369.77","other","OPPS APC"
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","216.98","363.89","66","352.08","369.77","other","OPPS APC"
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","515","352.08","369.77","other","OPPS APC"
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","221.41","221.41","221.50","631","352.08","369.77","other","OPPS APC"
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","AETNA [1001]","HB MCL AETNA","270.42","55.3","","428.84","428.84","499.06","106","244.5","595","percent of total billed charges",""
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","262.64","53.71","","727.78","271.03","727.78","34","244.5","595","percent of total billed charges",""
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","CIGNA ALTERNATE [1018]","HB MGB CIGNA EVERNORTH","244.50","50","","332.00","162.00","332.00","1 through 10","244.5","595","percent of total billed charges",""
"Therap Repetitive Ocd Tms Tx Subseq Delivery & Mng","PX-99900339","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","297.64","297.64","297.64","43","244.5","595","other","OPPS APC"
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","131.00","98.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","84.89","64.8","","120.64","120.64","120.64","1 through 10","16.8","99.56","percent of total billed charges",""
"Transcranial Mag Stim Ther Tx Initl","PX-90000001","CDM","90867","CPT","0900","RC","","","","both","","","822.00","616.50","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","591.84","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Initl","PX-90000001","CDM","90867","CPT","0900","RC","","","","both","","","822.00","616.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.97","380.97","381.12","17","369.77","591.84","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Initl","PX-90000001","CDM","90867","CPT","0900","RC","","","","outpatient","","","822.00","616.50","AETNA [1001]","HB MCL AETNA","454.57","55.3","","942.88","942.88","942.88","1 through 10","369.77","624.72","percent of total billed charges",""
"Transcranial Mag Stim Ther Tx Initl","PX-90000001","CDM","90867","CPT","0900","RC","","","","outpatient","","","822.00","616.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","348.62","348.62","348.62","1 through 10","369.77","624.72","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","AETNA [1001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.53","276.97","381.33","24","352.08","369.77","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","216.98","363.89","66","352.08","369.77","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","515","352.08","369.77","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","both","","","489.00","366.75","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","221.41","221.41","221.50","631","352.08","369.77","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","AETNA [1001]","HB MCL AETNA","270.42","55.3","","428.84","428.84","499.06","106","244.5","371.64","percent of total billed charges",""
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","262.64","53.71","","727.78","271.03","727.78","34","244.5","371.64","percent of total billed charges",""
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","CIGNA ALTERNATE [1018]","HB MGB CIGNA EVERNORTH","244.50","50","","332.00","162.00","332.00","1 through 10","244.5","371.64","percent of total billed charges",""
"Transcranial Mag Stim Ther Tx Per","PX-90000002","CDM","90868","CPT","0900","RC","","","","outpatient","","","489.00","366.75","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","297.64","297.64","297.64","43","244.5","371.64","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Redet","PX-90000003","CDM","90869","CPT","0900","RC","","","","both","","","610.00","457.50","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","439.2","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Redet","PX-90000003","CDM","90869","CPT","0900","RC","","","","both","","","610.00","457.50","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.32","319.32","319.45","16","369.77","439.2","other","OPPS APC"
"Transcranial Mag Stim Ther Tx Redet","PX-90000003","CDM","90869","CPT","0900","RC","","","","outpatient","","","610.00","457.50","AETNA [1001]","HB MCL AETNA","337.33","55.3","","900.28","900.28","900.28","1 through 10","305","463.6","percent of total billed charges",""
"Transcranial Mag Stim Ther Tx Redet","PX-90000003","CDM","90869","CPT","0900","RC","","","","outpatient","","","610.00","457.50","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","287.50","287.50","287.50","1 through 10","305","463.6","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Delivery/Management","PX-96100060","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","AETNA [1001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.53","276.97","381.33","24","213.12","369.77","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Delivery/Management","PX-96100060","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","216.98","363.89","66","213.12","369.77","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Delivery/Management","PX-96100060","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","515","213.12","369.77","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Delivery/Management","PX-96100060","CDM","90868","CPT","0961","RC","","","","both","","","296.00","222.00","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","221.41","221.41","221.50","631","213.12","369.77","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Delivery/Management","PX-96100060","CDM","90868","CPT","0961","RC","","","","outpatient","","","296.00","222.00","AETNA [1001]","HB MCL AETNA","163.69","55.3","","428.84","428.84","499.06","106","158.98","595","percent of total billed charges",""
"Transcranial Magnetic Stimulation Treatment,Delivery/Management","PX-96100060","CDM","90868","CPT","0961","RC","","","","outpatient","","","296.00","222.00","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","158.98","53.71","","727.78","271.03","727.78","34","158.98","595","percent of total billed charges",""
"Transcranial Magnetic Stimulation Treatment,Delivery/Management","PX-96100060","CDM","90868","CPT","0961","RC","","","","outpatient","","","296.00","222.00","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","297.64","297.64","297.64","43","158.98","595","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Planning","PX-96100059","CDM","90867","CPT","0961","RC","","","","both","","","879.00","659.25","MEDICARE [2001]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","12","369.77","632.88","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Planning","PX-96100059","CDM","90867","CPT","0961","RC","","","","both","","","879.00","659.25","MEDICARE ALTERNATE [2002]","HB MCL MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","380.97","380.97","381.12","17","369.77","632.88","other","OPPS APC"
"Transcranial Magnetic Stimulation Treatment,Planning","PX-96100059","CDM","90867","CPT","0961","RC","","","","outpatient","","","879.00","659.25","AETNA [1001]","HB MCL AETNA","486.09","55.3","","942.88","942.88","942.88","1 through 10","344","1023.79","percent of total billed charges",""
"Transcranial Magnetic Stimulation Treatment,Planning","PX-96100059","CDM","90867","CPT","0961","RC","","","","outpatient","","","879.00","659.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","369.77","","APC Price ($369.77).","348.62","348.62","348.62","1 through 10","344","1023.79","other","OPPS APC"
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","103.00","77.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","66.74","64.8","","99.66","99.66","99.66","1 through 10","13.24","78.28","percent of total billed charges",""
"Visit Esketamine 56m or Less","PX-90000163","CDM","G2082","HCPCS","0914","RC","","","","both","","","2818.00","2113.50","MEDICARE [2001]","HB MCL MEDICARE","1366.15","","APC Price ($1,366.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1366.29","1366.29","1366.29","1 through 10","1366.15","2028.96","other","OPPS APC"
"Visit Esketamine 56m or Less","PX-90000163","CDM","G2082","HCPCS","0914","RC","","","","outpatient","","","2818.00","2113.50","AETNA [1001]","HB MCL AETNA","1558.35","55.3","","1561.43","1561.43","1561.43","1 through 10","344","2810.18","percent of total billed charges",""
"Visit Esketamine 56m or Less","PX-90000163","CDM","G2082","HCPCS","0914","RC","","","","outpatient","","","2818.00","2113.50","BLUE CROSS BLUE SHIELD [110001]","HB MCL BLUE CROSS MEDICARE REPLACEMENT","1513.55","53.71","","1344.43","1344.43","1344.43","12","344","2810.18","percent of total billed charges",""
"Visit Esketamine, > 56m","PX-90000164","CDM","G2083","HCPCS","0914","RC","","","","both","","","4007.00","3005.25","AETNA [1001]","HB MCL MEDICARE","1722.38","","APC Price ($1,722.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1773.32","1773.32","2182.03","1 through 10","1722.38","2885.04","other","OPPS APC"
"Visit Esketamine, > 56m","PX-90000164","CDM","G2083","HCPCS","0914","RC","","","","both","","","4007.00","3005.25","COMMONWEALTH CARE ALLIANCE [1007]","HB MCL MEDICARE","1722.38","","APC Price ($1,722.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1695.00","1695.00","2077.35","15","1722.38","2885.04","other","OPPS APC"
"Visit Esketamine, > 56m","PX-90000164","CDM","G2083","HCPCS","0914","RC","","","","both","","","4007.00","3005.25","MEDICARE [2001]","HB MCL MEDICARE","1722.38","","APC Price ($1,722.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.907). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1722.56","1722.56","1722.56","131","1722.38","2885.04","other","OPPS APC"
"Visit Esketamine, > 56m","PX-90000164","CDM","G2083","HCPCS","0914","RC","","","","outpatient","","","4007.00","3005.25","AETNA [1001]","HB MCL AETNA","2215.87","55.3","","2220.31","2220.31","2220.31","52","344","3994.62","percent of total billed charges",""
"Visit Esketamine, > 56m","PX-90000164","CDM","G2083","HCPCS","0914","RC","","","","outpatient","","","4007.00","3005.25","TUFTS HEALTH PLAN [170001]","HB MCL TUFTS MEDICARE REPLACEMENT","1722.38","","APC Price ($1,722.38).","1319.12","1319.12","1357.97","1 through 10","344","3994.62","other","OPPS APC"
"Visit Esketamine, > 56m","PX-90000164","CDM","G2083","HCPCS","0914","RC","","","","outpatient","","","4007.00","3005.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB MCL MEDICAID","2596.54","64.8","","950.50","950.50","950.50","11","344","3994.62","percent of total billed charges",""